Benign Stupors: A Study of a New Manic-Depressive Reaction Type

by August Hoch

of deeper stupor she had the automatic type of resistiveness but also outbursts of anger, particularly toward the nurses, striking one of them she said, "You are the cause of it all." When food was offered her, she said, "I wonder people would not leave me alone sometimes." Again, when her bed was approached, she would clutch and hold the bed clothes in an apparently aimless way as if the impulse to resist never reached its goal. Retrospectively she could not account for her muscular rigidity on the basis of definite ideas, and could recall only that she felt stubborn. In a later period when more accessible, she felt cross and did not want to be bothered. This emotional attitude was quite conscious with her, whereas the acts and speech of the earlier period, when her stupor was more profound, seemed more automatic and impulsive. In other words, the resistiveness looks like a larval attempt to express an idea which is probably not fully conscious and therefore gives the appearance of being aimless. As another example of this we may cite the case of Pearl F. (Case 9), who said when she recovered, "I was stubborn." In addition to the muscular resistiveness she had shown, she would often bite the bed clothes or scratch herself when she was approached. Mary F. (Case 3), while in a stupor, slapped at nearby patients quite aimlessly. When somewhat better, this conduct appeared in a more conscious form, as sullenness, indifference and smearing of feces (again the behavior of a naughty child). Here one might quote Laura A. once more, whose resis

tiveness when stuporous was intense but who in her manic spells expressed her negativism in a definite idea, "I don't want my face washed."

To summarize, then, we may say that negativism is apparently the result of a desire to be left alone, and that muscular resistiveness is a larval exhibition of the same tendency. But the appearance of this attitude in such aimless, impulsive acts or habits reminds us strongly of the dissociation of affect, which was commented on in the previous chapter. It would seem to be another example of this rather fundamental tendency of the stupor reaction, not merely to diminish conative reactions in general, but to reduce their appearance to that of isolated, partial and therefore rather meaningless expression.

3. Catalepsy. The last of the cardinal symptoms to be considered is catalepsy. It occurred in thirteen of thirty-seven cases, although it was present only as a tendency in three of these. If we define it as the maintenance of position in which a part of the body is placed regardless of comfort, we can see that sometimes it is difficult to differentiate from the phenomenon of resistiveness with its rigidity. It is most frequently observed in the hands and arms, perhaps because it is, as a rule, most convenient to demonstrate the retention of awkward positions in the upward extremities. But any part or even the whole body may be involved; for example, Charles O. retained standing positions even where balance was difficult. This phenomenon is often

accompanied by "waxy flexibility," where the joints move stiffly but retain whatever bend is given them, like a doll with stiff joints.

The significance of catalepsy is best studied by considering its relationship to other symptoms and by noting remarks made by the patients in reference to it. The most important observations which we have made seem to indicate that it never occurs with that degree of deep inactivity which suggests a complete lack of mentation on the part of the patient. One is therefore forced to conclude that back of this phenomenon there must be some purpose, some kind of an ideational content, although this may be of a primitive order. This is demonstrably true in some cases, at least such as that of Isabella M., who left her arm sticking up in the air but took it down to scratch herself and then put it back. Somewhat similarly, Charlotte W. (Case 12), when she was shown during convalescence a photograph of herself in a cataleptic state, said that that was when she was waiting to go to Heaven and was afraid to move. Again she remarked, "I was mesmerized." Josephine G., who showed only a tendency to catalepsy, said that she feared the devil would get control of those about her if she moved. Sometimes there is a development of this symptom from others which seem to be ideational in their origin. For instance, Charles O. began making flail-like movements. These passed over into slow circular motions which finally subsided into the maintenance of fixed position.

References to hypnotism are not infrequent, and in many cases there is evidence of a delusion that the posture is desired by those in charge of the patient. Annie G. (Case 1) said so directly. In retrospect she explained the holding of her arms in the air by saying, "I thought you wanted me to have them up." Henrietta B. at one examination kept her arms raised in the position in which they had been put for a minute and then dropped them, saying, "Stop mesmerizing me." But she then put them up again of her own accord and now presented intense resistance to any motion. Later she extended her arms in front of her and said, "I am all right," in a theatrical manner. Some patients give evidence in other symptoms of larval efforts at coöperation with the actual or supposed wishes of the physician and in such cases it is not impossible that passive movements are interpreted as orders. One must remember in this connection that the more primitive are the mental operations of any individual, the more important do signs, rather than speech, come to be a medium of communication with other people. As an example of this type we might mention Rose Sch. (Case 6), who flinched from pin pricks (showing that she felt them) but made no effort to get away. When somewhat clearer she said that she was "here to be cured." Similarly Mary D. (Case 4), who showed no catalepsy from ordinary tests, kept her head off the pillow for a long time after it was raised to have her hair dressed. She showed such perseveration in many constrained po

sitions. She too flinched from pin pricks but not only made no effort to prevent them but would even stick out her tongue to have a pin stuck in it.

The relationship of catalepsy to resistiveness is interesting but unfortunately complicated and unclear. In only one of our cases was catalepsy definitely present without resistiveness, and in one other a "tendency to catalepsy" was noted without muscular rigidity being observed. In this latter case, when the catalepsy became unquestionable, resistiveness also appeared. It is one thing to note this coexistence and another to explain it adequately. All that we can offer are mere speculations as to the real meaning of the association of these phenomena. It may be that the tension of muscles that occurs when resistiveness is present gives the idea to the patient of holding the position. There would be two possible explanations for this. We might think there is a dissociation of consciousness, like that of hysteria, where the feeling of tenseness in the muscles that comes from the resistance to gravity is not discriminated from the resistance to the movements made by the examiner. On the other hand, there might be a similar dissociation where the perception of contraction in the antagonistic muscles is interpreted as the action of the examiner in placing the limb in a given position. This latter view would seem, on the face of it, ridiculous, inasmuch as its presumes the existence of two directly opposed tendencies, namely, those of opposition to the will of the physician and compliance with it. But